NCC232952_FRO Submitted_20231003

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Gold Leaf Crossing
2. Location of land-disturbing activity: County Wake City or Township Fuquay-Varina
Highway/Street US 401 Latitude(decimaIdegrees)35.596 g degrees)-78.751
Lon etude decimal
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial�j
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): / 3 , 0
6. Amount of fee enclosed: $ 7,3 0 CI ,4 Q . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900)
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes❑ Enclosed IEI No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ron Stading E-mail Address [e-mail]
Phone: Office# 704-332-0851 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Adcock Family Interests, LLC 919-418-4035
Name Phone: Office# Mobile#
114 E Spring St same
Current Mailing Address Current Street Address
Fuquay-Varina, NC 27526
City State Zip City State Zip
10. Deed Book No.017296 Page No. 01779/01771 Provide a copy of the most current deed.
1775/1766

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)if the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies)
FV Retail, LLC [e-mail]
Company Name E-mail Address
831 E Morehead St, Suite 445 Same
Current Mailing Address Current Street Address
Charlotte, NC 28202
City State Zip City State Zip
Phone: Office# 704-342-0410 Mobile# [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
James S Donaldson [e-mail]
Name of Registered Agent E-mail Address
831 E Morehead St, Suite 445 Same
Current Mailing Address Current Street Address
Charlotte, NC 28202
City State Zip City State Zip
Phone: Office# 704-342-0410 Mobile# [phone]
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Richard A. Barta Manager
Type or print name Title or Authority
411/110-ir-i
B . 3/442.1.,
•�:' . Dat�
I, (_ t r1Iik 2 W tx'01 , a Notary Public of the County of Ga -.1-o,
State of North Carolina, hereby certify that Rja r'C` 4. GZrtL, appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1 ,z day of J[,C)j , 20
Notary"
My commission expires (l` I ad97�0
�3,
NOTARY O
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
FV Retail LLC 704-342-0410 704-904-8917
Name Phone: Office# Mobile#
831 E Morehead St, St 445 Same
Current Mailing Address Current Street Address
Charlotte, NC 28202
City State Zip City State Zip
Deed Book No. 018832 Page No.01475 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#